Becoming a Donor to a Human Milk Bank

We provide articles
from our publications from previous years for reference for our Leaders and
members. Readers are cautioned to remember that research and medical information
change over time

A One-Minute History of
Donor Milk Banking in the USA

Throughout history there
have been numerous examples of women who breastfed or otherwise provided
their milk for infants who were not their biological offspring. Prior
to the advent of commercial formulas, wet nursing was frequently the
only way for an infant to survive. As wet nurses became harder to find,
physicians interested in the survival of infants and children looked
for other ways to provide human milk to sick children. Thus the concept
of donor human milk banking was born. In the US the first donor milk
bank was founded in Boston in 1911. Unwed mothers were paid to provide
their milk to hospitalized infants. They continued to nurse their own
infants to maintain a milk supply, and were screened for disease through
a physical examination. Milk was also pasteurized. During the late 1920s
there were numerous donor milk banks in the USA, including one in the
Chicago area which sent milk to the Dionne Quintuplets in Canada in
1934. The American Academy of Pediatrics first published guidelines
for milk-banking operations in 1943.

Donor milk banking is defined
as the collection, screening, processing, and distribution of human
milk from volunteer breastfeeding mothers. Donor milk is dispensed only
by prescription to individuals with medical and/or nutritional needs
which require human milk. Over the years donor milk banking has fallen
in and out of favor with the medical community. During the 1970s when
neonatology became a field of its own and smaller and smaller premature
infants began to survive, donor milk was an integral part of feeding
these infants, and numerous donor milk banks existed around the country.
The emphasis shifted in the 1980s when formulas designed especially
for premature babies were introduced and HIV became a concern. As we
head into the 21st century, the appropriate emphasis in Neonatal Intensive
Care Units is for mothers of premature infants to provide their own
milk. Use of donor milk has shifted in the last 10 years from being
used nearly exclusively for premature infants to currently being used
for older infants and children with major nutritional or immunological
problems, as well as for the occasional adult (see Table 1 Clinical
Uses). There has been an increasing trend in the use of this prescription
item as well as the expansion of the US donor milk banking network with
the 1999 opening of a new milk bank in Austin Texas. Current barriers
to increased usage are lack of physician awareness of the service and
lack of national policy supporting the use of donor milk in certain
clinical situations.

Risks of Informal Sharing
of Milk

In the age of potential transmission
of HIV, hepatitis, and other viruses through human milk, there is an
increased risk of using a wet nurse. There are also new strains of bacteria
that are becoming drug resistant and extremely dangerous. Informal sharing
of milk between nursing mothers who care for each other's children and
nurse them, or sharing expressed milk with a friend or neighbor or acquaintance
is not advisable. Furthermore, the Centers for Disease Control and Prevention
specifically recommend against this informal sharing of milk.

Donor milk banks have put
several safeguards into place to prevent the possibility of disease
transmission. First, all donors are carefully screened for diseases
of various kinds before their milk is accepted. In the informal sharing
situation this safeguard is usually absent. Additionally, donor milk
banks pasteurize all milk prior to distribution and check it for bacterial
content. This safeguard is also not present when women share milk with
each other informally.

Because some individuals
may have a viral or bacterial infection but remain asymptomatic (without
symptoms), they may never know that they are infecting another party.
For this reason, "knowing someone well" would be inadequate
protection against disease transmission because the carrier is unaware
she is infected. In the case of sexually transmitted diseases or illegal
drug use, people may go to extremes to protect discovery of the behavior
that led to the infection.

Finally, there have been
cases where family members have nursed or provided milk for each other's
children. This might be considered very safe by some individuals, but
for the same reasons listed above may prove to be unsafe. Imagine the
strain on a family relationship and dynamic, not to mention the guilt,
if a child should become ill because of a disease that was transmitted
via the shared milk of a relative.

Perhaps the only exception
to this situation might be in a hospice situation where the recipient
of the milk is not expected to live. In this case, milk from a family
member may alleviate suffering and discomfort caused by medications
or the disease itself. Family members should not expect a quick fix,
however, and should discuss the options thoroughly and be fully aware
of the possibility of disease transmission.

What It Takes to Be a Donor

Donors are critical to the
success of a donor milk bank. Without donors to provide a safe and continuous
supply of milk, infants and children who need donor milk would be deprived
of access to this valuable resource. The human milk donor must be in
good health, have a milk supply in excess of her own infant's needs,
and be motivated to express and donate to the milk bank using the collection
protocols provided by the milk bank. She cannot be high-risk for transmission
of blood-borne diseases. No donor receives payment for her milk.

Most donors choose to express
several ounces a day for donation over a period of several weeks or
months. Other mothers discover that they have pumped far more than their
own babies will need and may choose to make a one time donation of several
hundred ounces. Some mothers may donate accumulated expressed milk after
a baby dies. This can be a very important part of healing for many families
while they grieve an infant's loss.

The screening process for
becoming a donor is a two-stage procedure. First the donor answers a
detailed health history questionnaire. An additional form goes to her
primary care provider to verify the accuracy of her health self-assessment.
Potential donors may be excluded for the following reasons:

receipt of a blood transfusion
or blood products within the last 12 months.

receipt of an organ or
tissue transplant within the last 12 months.

regular use of more than
two ounces of hard liquor or its equivalent in a 24-hour period.

regular use of over-the-counter
medications or systemic prescriptions (insulin or thyroid replacement
hormones and progestin-only birth control products are acceptable).

total vegetarians (vegans)
who do not supplement their diet with B-12 vitamins.

use of illegal drugs.

use of tobacco products.

a history of hepatitis,
systemic disorder of any kind, or chronic infections (eg., HIV, HTLV,
tuberculosis).

had a sexual partner in
the last 12 months who is at risk for HIV, HTLV, or hepatitis (including
anyone with hemophilia, or who has ever used a needle for prescription
or non-prescription drugs, or who has taken money or drugs or for
sexual favors).

Once the prospective donor
has completed the health history, she then enters stage two of the donor
process and is tested serologically (through blood tests) for HIV-1
and HIV-2, HTLV, Hepatitis B, Hepatitis C, and syphilis. New tests may
be added to this screening panel as new viruses emerge which could create
potential problems for recipients. Milk banks will cover the cost of
the serological screening. Repeat donors are treated as new donors with
each pregnancy and must undergo screening again.

Collecting, Storing, Handling,
and Shipping

Individual milk banks have
protocols which they wish donors to follow while collecting milk. Instructions
about hygiene and hand washing as well as cleaning breast pumps and
collecting kits are provided. When a donor signs on prior to beginning
to collect milk, milk banks will provide her with sterile containers
in which to collect, store, and freeze her milk. If she is an out-of-state
donor she will be sent containers which will survive shipping and will
be given specific instructions on shipping her milk as well.

When a donor has already
collected a substantial quantity of milk prior to donating, it may be
accepted in a variety of containers. However, milk banks prefer to receive
milk in containers other than milk storage bags. First, the bags are
extremely messy to deal with in the milk bank. Even the heavier gauge
plastic bags tend to split or leak, and much valuable milk is lost in
this way. They are also much more difficult to pour from and allow numerous
opportunities for contamination. Furthermore, a significant amount of
fat remains behind on the surface of these bags and is wasted, thus
robbing the pool of donor milk of valuable calories, anti-infective
components and neurologically important fatty acids.

Each US milk bank adheres
voluntarily to the Human Milk Banking Association of North America's
(HMBANA) Guidelines for the Establishment and Operation of a Donor
Human Milk Bank. However, each milk bank operates within these Guidelines
in slightly different ways, so it is always best to check with the individual
milk bank about the specific protocols which it follows.

Simply because there are
no milk banks in a given state does not mean that individuals in that
state cannot donate milk. There are four milk banks in the country which
currently accept out-of-state donations and cover the cost of shipping
the milk from the donor to the milk bank. They provide shipping containers
and instructions for packing. While it is always more cost-effective
to obtain milk locally, it is not always possible for local donors to
meet recipient demand for donated milk, and so out-of-state donations
are accepted. If there is an ample supply of milk available locally,
then out-of-state donors may temporarily be turned away.

Once collected, the donated
milk is heat-treated to destroy any bacteria or viruses that may be
present. While some of the components of human milk are heat-sensitive
and are destroyed during the heating process, a substantial number still
remain functional in amounts higher than occur in formulas. For example,
the 50 percent of immunoglobulin A (IgA) which remains after human milk
is heat-treated is significantly better than the total absence of IgA
in formula! After processing, milk is stored frozen until it is needed.
Shipping of frozen milk is done by overnight delivery service and can
be delivered within 24 hours of receipt of a prescription.

A processing fee is charged
on a per ounce basis to the family of the donor milk recipient. This
fee helps to cover some of the costs of screening donors and processing
milk. It is not a charge for the milk itself. The average processing
fee within the United States is $2.50 per ounce. However, no individual
is denied access to donor milk for inability to pay, and milk banks
frequently write off large bills.

The Recipient Population

In the absence of the infant's
own mother's milk, donor milk offers all the benefits of human milk,
such as easy digestibility and immune substances to protect against
disease. Furthermore, because it is species-specific, complications
which arise with the use of breast milk substitutes are not seen.

Donor milk has a broad range
of therapeutic uses. For the infant who is failing to thrive because
of food intolerance, human milk may be a lifesaver. For the infant whose
tissues and organ systems need to mature or heal, donor milk provides
growth factors which facilitate these processes, helping tissues damaged
by illness to repair themselves, and helping the individual to regain
health. Donor milk may also help prevent certain conditions in prematurity
that are life-threatening.

Clinical uses of banked donor
milk may be arbitrarily divided into nutritional, medicinal or therapeutic,
and preventive uses. In practice, however, donor milk may serve several
purposes for the same recipient. For example, a preterm infant receives
not only nourishment from donor milk but also medicinal therapy in the
form of immune substances and growth factors present in donor milk.
Necrotizing enterocolitis and food intolerances are also being prevented
through the use of donor milk. Table 1 is a partial list of diagnoses
for which donor milk was prescribed in 1998.

How to Help Mothers Access
a Donor Milk Bank in the United States.

As an LLL Leader, you may
occasionally be approached by mothers who are looking for donated human
milk for their babies or mothers who want to donate milk. The list above
includes milk banks in the USA. (Table 2). Only the milk banks marked
with an asterisk (*) will accept out-of-state donors. Milk banks in
other countries are listed in Table 3.

Milk bank staff are extremely
busy and staff sizes vary as do the hours of operation. Frequently the
coordinator of the milk bank is also the lactation consultant for the
hospital in which the milk bank is located. She may be overworked and
overextended with little or no volunteer help in the office. For this
reason, potential donors should be advised to be persistent when they
do not have their messages returned in a timely fashion. As an example,
in the fall of 1998 there was one paragraph about the need for donors
that appeared in Baby Talk magazine. The office of HMBANA, which had
a toll-free number on my answering machine at the time, was inundated
with calls from 49 of the 50 states, upwards of 300 phone calls per
day for several months. Many prospective donors were very angry because
of the inability of one person to handle the volume of donor phone calls.
This is a plea to be patient, persistent, and understanding with milk
bank staff.

Comments
from Parents of Milk Bank Recipients

"Donor milk
meant the difference between life and death for my baby."

"As soon as
we put Lindsay on mother's milk, everything changed. She's a
to different baby...happy and peaceful."

"My child might
not have lived if it weren't for breast milk donations. She
is adopted and I couldn't provide her with mother's milk....
People don't realize that some children can't survive on formula
and some mothers can't provide their own milk"

"It was hard
to be a middle class family and know we could not buy or get
any food our child could eat from the grocery store. Without
donor milk, she could have starved to death in America."

"Unless you
have gone through months with a chronically ill infant, you
cannot appreciate how glorious it is to enjoy a healthy, happy
child. A baby so happy that after a feeding, he can lie in my
arms and look up at me with contentment and trust instead of
agony and confusion as to why eating is so awful."

United States Department
of Health and Human Services, Public Health Service. Guidelines for
preventing transmission of Human Immunodeficiency Virus through transplantation
of human tissue and organs. MMWR, Vol. 43, No. RR-8, May 20,1994.

Lois D. W. Arnold, MPH,
IBCLC, is President and CEO of the National Commission on Donor Milk
Banking. She is the former volunteer Executive Director of the Human
Milk Banking Association of North America. Inc. and was a founding member
of that organization. She has both national and international expertise
with donor milk banking and has a rich experience as a former donor,
collector, pasteurizer, and milk bank administrator.